Provider Demographics
NPI:1811132905
Name:CLARKE, MARISA
Entity type:Individual
Prefix:MS
First Name:MARISA
Middle Name:
Last Name:CLARKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:
Other - Last Name:TINAJERO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LVN
Mailing Address - Street 1:21505 NORWALK BLVD
Mailing Address - Street 2:
Mailing Address - City:HAWAIIAN GARDENS
Mailing Address - State:CA
Mailing Address - Zip Code:90716-1121
Mailing Address - Country:US
Mailing Address - Phone:562-916-7581
Mailing Address - Fax:
Practice Address - Street 1:801 E CHAPMAN AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-3839
Practice Address - Country:US
Practice Address - Phone:714-680-8265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-03
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225400000X103K00000X
CAVN717771164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst